1-1-1.     PURPOSE

This order provides specific direction for the reporting, investigation, and recording of air traffic incidents. Additional guidance is provided for the identification and correction of performance deficiencies through establishing a quality assurance program at the facility and regional level.  This order is designed to work in concert with current Federal Aviation Administration (FAA) Orders concerning facility evaluations, air traffic technical training, performance management systems, and bargaining unit contractual agreements.

1-1-2. DISTRIBUTION

This Order is distributed to selected offices in Washington Headquarters, Regional Offices, the William J. Hughes Technical Center, the David J. Hurley Air Traffic Control System Command Center, and the Mike Monroney Aeronautical Center.  Also, copies are sent to all air traffic control facilities, all international aviation field offices, and the interested aviation public.

1-1-3. CANCELLATION

This revision cancels FAA Order 7210.56B, Air Traffic Quality Assurance, dated June 15, 2001.

1-1-4. EXPLANATION OF CHANGES

Numerous editorial and formatting changes were made where necessary.  The significant changes encompass several Memorandums of Understanding (MOU) with the National Air Traffic Controllers Association (NATCA) and policy memorandums from the Director of Air Traffic, AAT-1.   Brief explanations of these changes are listed below.  If further information is desired, direct questions through the appropriate facility/regional staff to AAT-20.

a.        2-1-2 a. (4) Quality Assurance Programs Responsibilities, establishes the requirement for AAT-20 to conduct formal investigations for facilities with high or increasing numbers of operational errors or incidents.

b.        2-1-2 a. (5) Quality Assurance Programs Responsibilities, establishes recognition for facilities that achieve a million error free operations.

c.        2-1-2 b. Quality Assurance Programs Responsibilities, adds several more requirements and/or responsibilities for each Regional Air Traffic Division  (ATD) Manager. These new requirements have been adopted from policy memorandums distributed by the Director of Air Traffic, AAT-1 and include:

(1)     Provide a copy of all Regional and Facility Quality Assurance (QA) Orders and Operational Error/Deviation (OE/OD) prevention plans to AAT-20.

(2)     Annually review all QA and OE/OD prevention plans.

(3)     Ensure a “Back to Basics” approach is included in each OE/OD prevention plan.

(4)     Ensure each facility’s OE/OD prevention plan is facility specific.

(5)     Ensure regional/facility OE/OD prevention plans provide the means to identify and correct non-compliance or eliminate future non-compliance.

(6)     Provide trend analysis, statistical data and recommendations to assist facilities with their prevention efforts.

(7)     Establish methods for early identification of facility trends in order to raise awareness. OE/OD rates per 100,000 operations will be tracked and distributed to heighten awareness.

(8)     Ensure towers include a comprehensive plan to prevent surface incidents in their facility runway incursion prevention plan.

d.        3-1-2. Technical Training Discussions Definitions, adds the definitions of controller proficiency and performance.

e.        3-1-3. a. (1) Technical Training Discussions Responsibilities, redefines the use of certified radar playback tools as a performance management tool.

f.         3-1-3. a. (3) Technical Training Discussions Responsibilities Note, explains the intent of Technical Training Discussions (TTD) is to provide first level supervisors a formal venue to address and/or re-address identified proficiency/performance issues.

g.       3-1-3. c. (1) Technical Training Discussions Responsibilities, establishes the requirement for the facility staff to complete a report to the ATM, describing all technical training that was assigned and completed through the TTD process.

h.       3-1-3. e. Technical Training Discussions Responsibilities, establishes a Controller self-critique and its inclusion into their Technical Training Discussion (TTD).  To facilitate and assist employee self-development activities, an employee may request and receive a tape of his/her own session.  A self–critique, if discussed with the employee’s supervisor, may be included in the employee’s technical training discussion.

i.         3-1-4. b. Technical Training Discussions Responsibilities, adds the requirement for the employee  to sign for receipt of the discussion. It should be noted that the employee’s signature does not constitute agreement with the contents of the discussion, only that they have received a copy and a verbal briefing on its contents. Additionally, it adds the requirement to include previous Operational Errors (OE), Operational Deviations (OD), Quality Assurance Reviews (QAR), regional/national OE/OD trends, and facility evaluations.

j.         4-1-1. Air Traffic Incidents Definitions, adds specific definitions of air traffic incidents that were incorporated from FAA Order 8020.11.

k.       4-1-2. General Handling Procedures, adds the requirement to log all air traffic incidents as a QAR on FAA Form 7230-4, Daily Record of Facility Operation.

l.         4-1-2. b. (5) (b) Air Traffic Incidents General Handling Procedures, redefines the employee interview (formerly consult) and documentation of the interview.

m.      4-1-3. Quality Assurance Review outlines the QAR process as a means for facilities to identify and correct system deficiencies (not just employee deficiencies) in a timely manner.

n.       4-1-3. a. (4) Quality Assurance Review, adds Operational Error Detection Program (OEDP) alert to the QAR process. Existing standalone OEDP logs may be utilized in lieu of entries into the facility operational log (FAA Form 7230-4). This addition simply formalizes the current OEDP process on a national level. As with any investigation, the Air Traffic Manager shall ensure the investigation is conducted in sufficient depth to assess the system performance with reasonable accuracy. 

o.        4-1-3. d. Quality Assurance Review, re-emphasizes the need to conduct an investigation in sufficient detail as to accurately portray the incident and take appropriate corrective action.

p.        4-1-3. k. Quality Assurance Review, adds the requirement for a 45 day retention of all supporting documentation on all suspected losses of separation.

q.        4-1-4. c. and d. Emergencies, redefines the requirement to immediately notify AAT-200 on all significant emergencies and provide a preliminary report within 3 hours.

r.        4-1-5. Flight Assists, redefines the procedures for the handling of FAA Form 7230-6, Flight Assist Report and outlines the Regional and National Outstanding Flight Assist Award.

s.        4-1-7. Spill Outs, redefines the information needed on all spill outs.

t.         4-1-8. a. (3) Airspace Intrusions, adds the requirement of tracking and identifying aircraft that enter Special Use Airspace (SUA).

u.       4-1-9. Invalid Mode C Reporting, allows for the electronic distribution of invalid Mode C reporting.

v.        5-1-1. Air Traffic Operational Error and Deviations Investigations and Reporting, definitions are added to include technical violations, the Operational Error/Operational Deviation Steering Committee, controlled event, uncontrolled event, severity index, and operational error casual factors.

w.       5-1-2. Air Traffic Operational Errors and Deviations Investigations and Reporting, Suspected Event, redefines Air Traffic Policy that any employee who is aware of any occurrence that may be an operational error, operational deviation, or air traffic incident (as defined in paragraph 4-1-1, Definitions) immediately notify the appropriate management official.

x.        5-1-3. Initial Investigations, outlines the intent and process the Investigator-in-Charge should follow with a preliminary investigation.  Additionally, it stipulates the need for a timely interview and a written statement from all involved employees and the initial return to duty process under the severity index classification process (See Chapter 6, Severity Index). Keep in mind; if during the preliminary investigation a loss of separation can be attributed to ATC, then a preliminary report should be completed. If both ATC and the Flight Crew of an aircraft are contributory, then both reports should be completed.

y.        5-1-4. Multiple Losses of Separation During a Single Event, the return to duty process will be based on the higher severity event when multiple errors occur and the return to duty plans will be combined.

z.        5-1-5. Investigative Process, redefines the guidelines to help assure a comprehensive and accurate investigation is completed.

aa.     5-1-7. Reclassification, reinforces the ATD responsibility to validate each reclassification request individually and, if warranted, coordinate a reclassification with AAT-200.

bb.     5-1-8. Performance Based Actions, performance management is a daily task. It is incumbent upon every one to identify and address their individual proficiency. Additionally:

(1)     Decertification shall not be based solely on the number of or involvement in an OE, but rather on the employees’ overall performance history.

(2)     The revocation or suspension of control tower operator certificate and facility ratings shall not be used for addressing performance deficiencies.

(3)     No employee will be decertified or required to complete remedial training for any operational error(s) classified as low severity or any operational deviation.

cc.      5-1-9. Return to Operational Duty,

(1)     All employees found to be primary/contributory to a low severity error shall be returned to operational duty as soon as the preliminary investigation is completed. No skill check or follow-up skill check shall be completed. Skill Enhancement training may only be assigned if the event was classified as uncontrolled.

(2)     All employees found to be primary/contributory to a moderate or high severity, as well as all surface, MVA/obstruction, oceanic/non-radar errors or at a facility where radar data is not available and where less than 80% of the separation standard was maintained, shall not be returned to operational duty until the provisions of paragraph 5-1-9, Return to Operational Duty are completed. Skill enhancement training or decertification and remedial training may be administered if the employees’ documented performance history warrants such action.

dd.     5-1-12. Skill Enhancement Training, is designed to increase the proficiency of a specialist in a skill or task on a position on which the specialist is certified. Based on the circumstances unique to a specific error, skill enhancement training need not always be accomplished prior to an employee continuing operational duties. Skill enhancement training shall be based upon the factors identified during the investigation.

ee.     5-1-15. a. (3) Documentation Retention, all supporting documentation, including the original NTAP or CDR plot shall be retained in approved electronic media, as well as all documentation, i.e. the supervisor’s return to duty plan, performance skill checks and severity index chart.

ff.       5-1-15. b. Documentation Retention, preliminary and final OE reports that are classified as low severity and/or OD reports, while retained for 2 1/2 years, shall be sanitized after 12 months so that any information, which could lead to the identification of an employee, either primary or contributory to the OE/OD, has been removed.

gg.    5-1-15. c. Documentation Retention, all references to a specific OE/OD shall be removed from the employees’ FAA Form 3120-4 and returned to the employee 2 1/2 years after the incident. All references to a specific OE classified as a low severity and/or OD shall be removed from the employees’ FAA Form 3120-4 and returned to the employee 12 months after the incident.

hh.    5-1-16. b. (6) Headquarters and Air Traffic Division Roles and Responsibility, changes the requirement to; All ATDs shall establish a follow-up mechanism to determine if corrective actions contained in FAA Forms 7210-3 are effective and are accomplished in a timely manner. All corrective actions shall specify a completion deadline.

ii.       6-1-1. Severity Index, as recommended by the U.S. Department of Transportation, Office of Inspector General, we have developed a method to determine severity, or collision hazard, for operational errors that occur in-flight.  In addition, the Memorandum of Understanding (MOU) between the National Air Traffic Controllers Association (NATCA) and the Federal Aviation Administration (FAA), dated January 17, 2001, stipulated that an operational error classification system be developed and implemented no later than April 30, 2001.  A classification model was developed as a result of studying numerous operational errors throughout the nation.  The model selected is based upon a total of 100 points made up of several factors including vertical and horizontal separation distances, flight paths and cumulative closure rates, as well as the level of air traffic control involvement.  A validation and testing period was completed to ensure that the model accurately captured each airborne event. This classification system was put into full implementation on April 1, 2001.

(1)     The model for classification of each airborne OE that occurs in domestic airspace includes components that are allotted point values corresponding with their relative significance during the event.  To achieve an accurate determination, a radar playback, with voice, of each airborne OE should be prepared so each event can be viewed repeatedly, if necessary.  It is important that OE’s be assessed in a timely manner so field managers are able to make informed operational and personnel decisions.  For these reasons, compliance with the following procedures is required.  If any problems arise which make compliance with these procedures unlikely, coordination with AAT-200 is required.

(2)     Each applicable OE shall be analyzed and assessed by AAT-200 personnel and a determination made as to the severity of the event.  Each OE that occurs in domestic airspace, under radar control, will be rated and categorized into one of three levels of severity.  Most final determinations will be completed within 10 business days of the initial OE call-in to AAT-200.

(3)     After carefully analyzing each event, point values will be assessed for several operational factors and once totaled this cumulative number will fall into a range that defines each category.

jj.       7-1-1. En-route Operational Error Detection Program (OEDP), outlines the en-route procedures to be followed when a facility receives an OEDP alert.

kk.   7-1-2. OEDP Audit, outlines the requirement for en-route facilities to develop a process to audit their internal OEDP alert validation process.

ll.       Appendix 1, Radar Data Processing; NTAP, SATORI, CDR plots, Radar Audio Playback Terminal Operations Recording (RAPTOR), Radar View Point, MSDT, ATC Plot and other reduction or playback tools are available to assist in investigations.  As technological advances are made, the ATC system must adjust to these changes and ensure that radar reduction tools are used correctly and consistently throughout the system in order to provide the most accurate recreation possible.

(1)     NTAP, SATORI, CDR data, and other reduction or playback tools shall not be arbitrarily used as the primary initiating source (triggering event) for reporting an OE/OD or commencing an investigation.   However, these reduction/playback tools may be used in the investigation of suspected incidents to determine the amount of separation that existed or the position of aircraft.  Additionally, these tools may be used for individual employee performance review/improvement and/or system/facility evaluation. When this is accomplished and a loss of separation is discovered, that error shall be reported, but attributed to the facility as a facility error. Skill enhancement training may be assigned to those employees’ determined to be contributory to these events. However, decertification shall not be imposed.

(2)     SATORI, RAPTOR or other playback tool may be used in the investigation of a QAR, suspected OE/OD, pilot deviation, NMAC, TCAS event, miscellaneous incident, or accident; to determine the relative flight tracks, speeds, headings, location and separation of the involved aircraft.  These tools may be used to determine controller and/or pilot performance and/or involvement in the incident, as well the aircrafts closest proximity.

mm.       Appendix 1-2, en-route LST 5 measurements data are more precise than NTAP measurements. Whenever possible a LST 5 shall be used to determine closest proximity.

nn.     Appendix 1-3, Continuous Data Recording (CDR), defines terminal radar data classes.

oo.      Appendix 1-4, defines CDR extraction and voice recording procedures.

pp.      Appendix 2 and 3, adds the new preliminary operational error/deviation instructions and report.

qq.      Appendix 3 and 4, FAA Form 7210-3, Final Operational Error/Deviation Report, changes include, addition of the severity index. Elimination of the employees name and addition of employees last six digits of their social security number for identification purposes.

rr.      Appendix 9, FAPM 2635 was recently replaced with the FAA Human Resource Policy Manual. The interview statement has changed and stipulates that it is the duty of every employee to give to any supervisor or official conducting an official investigation or inquiry, all information and testimony about all matters inquired of, arising under the law, rules, and regulations administered by the FAA.  Additionally, it is the responsibility of every employee to make themselves available as directed so that such an interview may be accomplished (as outlined in FAA Human Resource Policy Manual, ER 4.1 Standards of Conduct). As appropriate the interview statement shall be read or given to an employee before conducting an interview.

ss.      Appendix 10, General Reporting Procedures, adds a quick reference chart for the reporting of all air traffic incidents.

tt.        Appendix 11, Air Traffic Incident Handling Procedures, adds a generalized quick reference page for specific air traffic incidents and their notification requirements.

uu.     Appendix 12, Data Retention adds a quick reference chart for document retention requirements.

vv.       Appendix 13, adds a quick reference page for the handling of operational errors/deviations and the return to duty process.

1-1-5. EFFECTIVE DATE

This Order is effective August 15, 2002.

1-1-6. RELATED PUBLICATIONS

The following publications are the primary references to be used in coordination with provisions of this order:

a. FAA Order 3120.4, Air Traffic Technical Training.

b. FAA Order 7010.1, Air Traffic Evaluations.

c.       FAA Order 7110.10, Flight Services.

d. FAA Order 7110.65, Air Traffic Control.

e.       FAA Order 7210.3, Facility Operation and Administration.

f.        FAA Order 8020.11, Aircraft Accident and Incident Notification, Investigation, and Reporting.

1-1-7. USE OF TERMS

First-Level Supervisor shall include the Air Traffic Manager (ATM) wherever the ATM also performs such duties.

First-Level Supervisor, ATM, etc., shall include their official designees, except where specifically noted, for the purpose of accomplishing roles and responsibilities.

Establish, Designate, Identify, Develop, Waive, Authorize etc., shall be understood to require such actions to be specific and in writing.

1-1-8. SCOPE

Quality assurance is a dynamic process used to continually improve the air traffic system.  Although we will continue to measure the quality of our service by some historical methods, such as the number of operational errors, delays, employee and customer feedback, we must also recognize factors that cannot as readily be measured.  Our willingness to function as a team, our training, and the actions taken to support the goal of zero operational errors all factor into quality assurance.  The success of our quality assurance efforts is dependent on the recognition by the entire air traffic workforce that all of us, independently and collectively, must strive to provide the best service possible.  We are all accountable for the quality of that service.